Informed

Principal or Primary Diagnosis for Chemotherapy Administration

According to the ICD Manual guidelines, encounter for antineoplastic chemotherapy (ICD-10 code Z51.11) or encounter for antineoplastic immunotherapy (ICD-10 code Z51.12) must be the principal or primary diagnosis, followed by the diagnosis of the current acute disease or injury for chemotherapy administration (96401-96450, 96542-96549).

Procedures that are Bilateral in Nature (Bilateral Indicator 2)

These procedures do not have a unilateral counterpart, and the payment is based on the procedure being performed bilaterally. When these procedures are billed with a single anatomic modifier (LT or RT), then modifier 52 (Reduced) service should be appended.

Modifier -91 Repeat Clinical Diagnostic Laboratory Test

The billing of modifier -91 is used to report the same lab test when performed on the same patient on the same day and to obtain subsequent test results.

When reporting lab procedures, modifier 59 is used when the same lab procedure is done, but different specimens are obtained, or the cultures are obtained from different sites.

Example: Influenza A and influenza B are 2 separate strains, and you should bill 87804 for the first strain and 87804 with modifier -59 for the additional strain.

Dr. Kristine Carpenter, a Carle family medicine OB-GYN in Mattoon, IL, boasts high numbers when it comes to chlamydia screening rates. While the subject matter is sometimes tricky to approach, there is nothing tricky about her approach at all.

She realizes chlamydia is not every patient’s favorite topic and that it’s not always the easiest subject to bring up.

“I think STD screening kind of has a negative connation,” she said. “Some women come in wanting that screening, but if we don’t ask or bring it up, they’re not comfortable bringing it up.”

She suggests trying to take a conversational approach to a sometimes heavy and awkward discussion.

“When they say, ‘No I don’t really need it,’ or ‘I better not need it,’ or whatever it might be, I say, ‘That’s OK, I’ll ask you until you’re 90,’” she said. “They laugh, and it kind of becomes a light-hearted thing.”

She capitalizes on the natural opportunities to ask about chlamydia testing, like when she is putting in an intrauterine device or when a patient is pregnant.

“There’s a much higher rate of pelvic inflammatory disease if you do not check for that before you put in an IUD,” she said. “So if they happen to have chlamydia, when you put an IUD in, it can lead to pelvic inflammatory disease. In my training, I was always taught, before you put an IUD in, you should do that screening.”

The screening is recommended for sexually active women 24 or younger and those older and at an increased risk, and it can be done through a swab or urine test. Carpenter admits that most of the women she sees who aren’t already having a pelvic exam prefer the urine test over the swab.

She realizes the subject can be complex with teen patients who have parents with them, so Carpenter makes sure to always ask for one-on-one time with her patients to go over their rights and talk through topics they may not feel comfortable discussing in front of a parent.

“I think if we bring up the topic, more people would probably be willing to get the screening done,” she said. “I think it’s just asking. Especially in a women’s health exam, you have a lot of opportunity for preventive care, and this is just one aspect of that.”

Key Takeaways

Be persistent. Ask patients if they would like you to screen for chlamydia, even if they’ve turned you down in the past.

List the options. Patients who aren’t already having a pelvic exam might prefer the urine test over the swab.

While this device is available through certain DME providers and in retail pharmacies, we are only covering the Freestyle Libre under the DME benefit. We cover all continuous blood glucose monitors and their test strips under the DME benefit.

You can get the Freestyle Libre at:

EdgePark Medical Supplies – HA Provider ID #056804

Byram Healthcare – HA Provider ID #308677 (WA only)

You will have to submit preauthorizations through Clear Coverage for the Freestyle Libre, just as you would for other continuous blood glucose monitors. The HCPC codes for Freestyle Libre are K0553 and K0554, and they should be submitted together to cover the device and supplies.

If you have any questions, contact your provider relations specialist.

Utilization Review Determinations

As you all know, in 2017 we entered into a partnership with eviCore for managing certain preauthorization and utilization management requests. Some providers may be communicating to patients that eviCore is making coverage decisions.

We own all utilization review decisions, so any determinations made by us or through our partnership with eviCore should be communicated as coming from Health Alliance.

This helps our members avoid confusion and ensures they contact us directly when they need help. All members should be contacting us at the numbers on the back of their ID cards for any coverage concerns, regardless of how the review was processed.

Claims Editing Enhancements

Our claims editing program follows nationally accepted sources. We continuously deploy enhancements. These professional claims enhancements will be released in March:

Anatomical modifiers, as outlined in the HCPC manual on procedures that designate an area or part of the body for which the procedure was performed. When an anatomical modifier is not appended, then the procedure code will also be disallowed, and you must submit a corrected claim with the anatomical modifier.

Examples of anatomical modifiers:

E1-E4 – Eyelids

FA-F9 – Fingers

TA-T9 – Toes

LC – Left circumflex, coronary artery

LD – Left anterior descending coronary artery

LM – Left main coronary artery

RC – Right coronary artery

RI – Ramus intermedius

LT – Left side

RT – Right side

Anesthesia modifiers that show whether the service was personally performed, medically directed, medically supervised, or represented monitored anesthesia care for members on commercial plans. (In the past, we’d only required this for Medicare members.)

Similarly, CRNAs must report the appropriate anesthesia modifier to indicate whether the service was performed with or without supervision by a physician. When an anesthesia modifier is not appended to an anesthesia procedure, then the procedure code will also be disallowed, and you must submit a corrected claim with the anesthesia modifier.

Appropriate modifiers for anesthesia services are:

AA – Anesthesia services performed personally by an anesthesiologist

AD – Medical supervision by a physician: more than 4 concurrent anesthesia procedures

QY – Medical direction of one qualified nonphysician anesthetist by an anesthesiologist

QZ – CRNA without medical direction by a physician

You also should not bill multiple anesthesia modifiers AA, AD, QK, QX, QY, and QZ on the same claim line since they’re considered mutually exclusive.

ICD-10 laterality codes. Some ICD-10 codes specify if the condition occurs on the left or right or bilaterally. If no bilateral code is provided and the condition is bilateral, then you should use codes for both the left and right. If the side is not identified in the medical record, then you should use the unspecified code.

In addition, we will perform additional comparisons, such as:

The Diagnosis-to-Diagnosis comparison, which assesses the lateral diagnoses associated with the same claim line to determine if the combination is inappropriate

The Diagnosis-to-Modifier comparison, which assesses the lateral diagnosis associated with the claim line to determine if the procedure modifier matches the lateral diagnosis

We will be editing across same date of service for any Tax ID, any Provider ID, and specialty following Medicare CCI/MUE edits, as well as identification of duplicative services.

Diagnosis Codes and Risk Adjustment

Both the Medicare Advantage and commercial Marketplace condition category models are dependent on us receiving diagnosis codes through claims submission. We recommend that all claims submitted to us be coded to the highest level of specificity for the encounter reported. 2 areas of opportunity related to provider business processes that could significantly improve to support this higher level of coding accuracy include:

Code truncation, or limiting the number of diagnosis codes per claim submission

Claims not submitted at all (e.g. claims for capitated, custodial care, etc.)

These scenarios lead to inaccurate reporting of the overall risk of our population. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

New Medicare Numbers & Cards Coming in April 2018

Medicare is taking steps to remove Social Security numbers from Medicare cards to help fight fraud. People with Medicare will begin receiving new Medicare cards in April 2018, until all cards are replaced by April 2019. These cards will have a Medicare Beneficiary Identifier (MBI) number that is randomly generated.

Medicare will send people their new ID cards directly, and CMS will send us the new numbers to put in our system. This will not affect the ID cards we issue. Members may still get new ID cards from us as they renew, but that’s unrelated to the Medicare card changes.

HEDIS® Chart Reviews Coming Soon

Each spring, Health Alliance collects data to determine how we measure up against national averages for HEDIS® (the Healthcare Effectiveness Data and Information Set). This data collection and analysis indicates where we need to focus our quality efforts and is required for NCQA accreditation.

Successfully generating our HEDIS report depends largely on the cooperation we receive from provider office staff. Our representatives may visit your office this spring and ask to review specific medical records or ask you to copy, fax, or mail records to us as part of the audit. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations.

Results of the HEDIS audit will be available on our website in the fall of 2018.

If you have any questions about HEDIS, contact the Quality Management Department at 1-800-851-3379, ext. 8656.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Potentially Harmful Drug-Disease Interactions in the Elderly

Potentially Harmful Drug-Disease Interactions in the Elderly is a HEDIS measure that shows the percentage of Medicare members 65 years of age and older who have evidence of underlying diseases, conditions, or health concerns and who have filled prescriptions for potentially harmful medications. We’ve identified 2 conditions, history of falls and dementia, for review.

These tables show Health Alliance’s results from the HEDIS 2017 audit and the national average.

Percentage of members with a history of falls and a medication fill for anticonvulsants, non-benzodiazepine hypnotics, SSRIs, antiemetic, antipsychotics, benzodiazepines, or tricyclic antidepressants:

Service Area

HEDIS 2017

National Average

Illinois and Indiana

48.71%

47.27%

Washington

52.70%

47.27%

Iowa

47.50%

47.27%

Since a lower rate reflects better performance, our results are worse than the national average.

Percentage of members with diagnosis of dementia and a medication fill for antiemetic, antipsychotics, benzodiazepines, tricyclic antidepressants, H2 receptor antagonists, non-benzodiazepine hypnotics, or anti-cholinergic agents:

Service Area

HEDIS 2017

National Average

Illinois and Indiana

48.77%

46.24%

Washington

45.54%

46.24%

Iowa

Not enough data to report

The lower rate reflects better performance.

As you can see, our Medicare Advantage results are close to the same or worse than the national average.

Some of the most frequently prescribed medications on the potentially harmful medication lists are Zolpidem, Promethazine, Haloperidol, Alprazolam, Hydroxyzine, and Amitriptyline. If you have older patients on these medications or other medications in these drug classes, consider changing their medication to a safer alternative.

Pharmacy Update

All Plans

Morphine Equivalent Dose (MED) Coding

Tentatively expected by the end of January 2018

Formulary Additions

Shingrix vaccine – Approved for patients 50 years and older per MMWR recommendations.

Medicare – Tier 3 with 2 copays (one for each of the 2 injections) for patients over 50

Medicare

New Policies

AAT Deficiency

Created new AAT Deficiency policy to merge existing criteria from Aralast, Glassia, Prolastin-C, and Zemaira

Utilization Review Determinations

As you all know, in 2017 we entered into a partnership with eviCore for managing certain preauthorization and utilization management requests. Some providers may be communicating to patients that eviCore is making coverage decisions.

We own all utilization review decisions, so any determinations made by us or through our partnership with eviCore should be communicated as coming from Health Alliance.

This helps our members avoid confusion and ensures they contact us directly when they need help. All members should be contacting us at the numbers on the back of their ID cards for any coverage concerns, regardless of how the review was processed.

Claims Editing Enhancements

Our claims editing program follows nationally accepted sources. We continuously deploy enhancements. These professional claims enhancements will be released in March:

Anatomical modifiers, as outlined in the HCPC manual on procedures that designate an area or part of the body for which the procedure was performed. When an anatomical modifier is not appended, then the procedure code will also be disallowed, and you must submit a corrected claim with the anatomical modifier.

Examples of anatomical modifiers:

E1-E4 – Eyelids

FA-F9 – Fingers

TA-T9 – Toes

LC – Left circumflex, coronary artery

LD – Left anterior descending coronary artery

LM – Left main coronary artery

RC – Right coronary artery

RI – Ramus intermedius

LT – Left side

RT – Right side

Anesthesia modifiers that show whether the service was personally performed, medically directed, medically supervised, or represented monitored anesthesia care for members on commercial plans. (In the past, we’d only required this for Medicare members.)

Similarly, CRNAs must report the appropriate anesthesia modifier to indicate whether the service was performed with or without supervision by a physician. When a anesthesia modifier is not appended to an anesthesia procedure, then the procedure code will also be disallowed, and you must submit a corrected claim with the anesthesia modifier.

Appropriate modifiers for anesthesia services are:

AA – Anesthesia services performed personally by an anesthesiologist

AD – Medical supervision by a physician: more than 4 concurrent anesthesia procedures

QY – Medical direction of one qualified nonphysician anesthetist by an anesthesiologist

QZ – CRNA without medical direction by a physician

You also should not bill multiple anesthesia modifiers AA, AD, QK, QX, QY, and QZ on the same claim line since they’re considered mutually exclusive.

ICD-10 laterality codes. Some ICD-10 codes specify if the condition occurs on the left or right or bilaterally. If no bilateral code is provided and the condition is bilateral, then you should use codes for both the left and right. If the side is not identified in the medical record, then you should use the unspecified code.

In addition, we will perform additional comparisons, such as:

The Diagnosis-to-Diagnosis comparison, which assesses the lateral diagnoses associated with the same claim line to determine if the combination is inappropriate

The Diagnosis-to-Modifier comparison, which assesses the lateral diagnosis associated with the claim line to determine if the procedure modifier matches the lateral diagnosis

We will be editing across same date of service for any Tax ID, any Provider ID, and specialty following Medicare CCI/MUE edits, as well as identification of duplicative services.

Diagnosis Codes and Risk Adjustment

Both the Medicare Advantage and commercial Marketplace condition category models are dependent on us receiving diagnosis codes through claims submission. We recommend that all claims submitted to us be coded to the highest level of specificity for the encounter reported. 2 areas of opportunity related to provider business processes that could significantly improve to support this higher level of coding accuracy include:

Code truncation, or limiting the number of diagnosis codes per claim submission

Claims not submitted at all (e.g. claims for capitated, custodial care, etc.)

These scenarios lead to inaccurate reporting of the overall risk of our population. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

New Medicare Numbers & Cards Coming in April 2018

Medicare is taking steps to remove Social Security numbers from Medicare cards to help fight fraud. People with Medicare will begin receiving new Medicare cards in April 2018, until all cards are replaced by April 2019. These cards will have a Medicare Beneficiary Identifier (MBI) number that is randomly generated.

Medicare will send people their new ID cards directly, and CMS will send us the new numbers to put in our system. This will not affect the ID cards we issue. Members may still get new ID cards from us as they renew, but that’s unrelated to the Medicare card changes.

HEDIS® Chart Reviews Coming Soon

Each spring, Health Alliance collects data to determine how we measure up against national averages for HEDIS® (the Healthcare Effectiveness Data and Information Set). This data collection and analysis indicates where we need to focus our quality efforts and is required for NCQA accreditation.

Successfully generating our HEDIS report depends largely on the cooperation we receive from provider office staff. Our representatives may visit your office this spring and ask to review specific medical records or ask you to copy, fax, or mail records to us as part of the audit. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations.

Results of the HEDIS audit will be available on our website in the fall of 2018.

If you have any questions about HEDIS, contact the Quality Management Department at 1-800-851-3379, ext. 8656.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Potentially Harmful Drug-Disease Interactions in the Elderly

Potentially Harmful Drug-Disease Interactions in the Elderly is a HEDIS measure that shows the percentage of Medicare members 65 years of age and older who have evidence of underlying diseases, conditions, or health concerns and who have filled prescriptions for potentially harmful medications. We’ve identified 2 conditions, history of falls and dementia, for review.

These tables show Health Alliance’s results from the HEDIS 2017 audit and the national average.

Percentage of members with a history of falls and a medication fill for anticonvulsants, non-benzodiazepine hypnotics, SSRIs, antiemetic, antipsychotics, benzodiazepines, or tricyclic antidepressants:

Service Area

HEDIS 2017

National Average

Illinois and Indiana

48.71%

47.27%

Washington

52.70%

47.27%

Iowa

47.50%

47.27%

Since a lower rate reflects better performance, our results are worse than the national average.

Percentage of members with diagnosis of dementia and a medication fill for antiemetic, antipsychotics, benzodiazepines, tricyclic antidepressants, H2 receptor antagonists, non-benzodiazepine hypnotics, or anti-cholinergic agents:

Service Area

HEDIS 2017

National Average

Illinois and Indiana

48.77%

46.24%

Washington

45.54%

46.24%

Iowa

Not enough data to report

The lower rate reflects better performance.

As you can see, our Medicare Advantage results are close to the same or worse than the national average.

Some of the most frequently prescribed medications on the potentially harmful medication lists are Zolpidem, Promethazine, Haloperidol, Alprazolam, Hydroxyzine, and Amitriptyline. If you have older patients on these medications or other medications in these drug classes, consider changing their medication to a safer alternative.

Pharmacy Update

All Plans

Morphine Equivalent Dose (MED) Coding

Tentatively expected by the end of January 2018

Formulary Additions

Shingrix vaccine – Approved for patients 50 years and older per MMWR recommendations.

WA Public – Covered under the wellness benefit for patients over 50

Medicare – Tier 3 with 2 copays(one for each of the 2 injections) for patients over 50

WA Public Plans

Criteria Changes

Zurampic and Duzallo

Added Duzallo to Zurampic policy

New Policies

Triptodur

Tier 5 with preauthorization (PA)

Line extension of Trelstar

Tier Changes – Effective January 1, 2018

Daraprim – Moved from Tier 3 to Tier 6

Specialty drug

Price continues to increase

Manufacturer assistance available

Tier Changes – Effective March 1, 2018

Rx Medical Foods – Move from Tier 3 to Excluded

Excluded drug policy states that medical foods are excluded from coverage